REFERAT

VACCINES FOR THE ELDERLY

ABIDAH BAZLINAH DERMAWAN

I4061162040

Supervisor: dr. Achmadi Eko Sugiri, Sp.PD

 The number of elderly
population ↑, highest
acceleration in the world by
2020
Why vaccinate older persons?
• public health prevention
• Reduce morbidity, frailty, and even
death
• Reduce hospitalizations, suffering
• Enable productivity & ability to
work
Background
>> number geriatric pts as
they’re more vulnerable to
various conditions of illness
Age related changes of the
immune system →
↑incidence & severity of
infections in elderly
Vaccination is the most
effective measure to prevent
infections
frequently associated w/ long-term
sequelae such as impairments in
activities of daily living, onset of frailty,
or the loss of independence
 Eldely pts often
lack high-
affinity
antibody
responses to
infectious
agents &
vaccination

What happened to innate

immunity in elderly?
Hallmarks of immunosenescence
• Protection fx (epithelial cells in
→ gradual replacement of functional
skin, lung/GI tract) << →
thymic tissue by fat, leading to a
pathogens can easily invade
dramatically << output
mucosal tissue
of newly generated naive T cells,
• Chemotaxis is disturbed in
which is reflected by << numbers of
neutrophils, monocytes/
naive T cells
macrophages and dendritic cells
and impaired microbicidal fx →
<< phagosytosis

IMMUNOSENESCENCE
 • The consequences of immunosenescence: elderly are
susceptible to infectious diseases

• ↑ risk of maglinancies : The number of NK cells is even ↑

with age, however, NK cell functions (cytotoxicity
&cytokine production) <<

• immunosenescence→ << imunosurveillance against

maglinancies

IMMUNOSENESCENCE
 • Medical (lesser of insidence of hospitalization & complications)
and economic advantages (lesser expense → reduced
hospitalization cost as well as << treatment cost)

• Various studies have demonstrated the benefit of

immunization in decreasing morbidity and mortality.

• Spesific protection

• Prevention measure→ As severity and incidence of infections

increase with age, the elderly are a particularly important
target population for vaccination → prevent secondary impacts
(<< number of exacerbation of chronic condition)

• ↑ fungtional capacities : ADL, << dependencies, ↑ quality of

life

The Urgencies of Vaccines for the elderly


• Influenza: viral infection caused by influenza
viruses belonging to orthomyxoviridae family,
classified to type A (H1N1 & H3N3), B, C.
• causes approximately 100,000 hospitalizations
& 36,000 deaths annually in the USA, which
occur >> in persons over the age 65 years
• The prevalence of Influenza may reach 5-20%
of population each year along with high
mortality rate, especially among neonates and
the elderly population.
• In the population over 50 years of age, the
mortality rate is increasing with age
INFLUENZA IN ELDERLY
• The first symptoms in the elderly usually are
loss of appetite, weakness fatigue, & malaise.
• Other symptoms may include symptoms of
acute respiratory tract infection such as fever,
myalgia, and headache.
• The fever may be extremely high and last for at
least three days.
• Muscle pain may predominate in extremities,
orbital area, and the trunk. The symptoms may
be exaggerated by cough (initially appears as
anon-productive cough), sore throat and coryza.
• On physical examination, the elderly will appea
severely ill, had redness of the conjunctiva and
sometimes accompanied with lymph node
enlargement around neck (with tendernes)
• Respiratory tract
hyperreactivity and pneumonia
are the common complication
of influenza.
• complication of influenza in
• will result in reduced
functional status, prolonged
recovery time (post-influenza
asthenia) with highdependency
rate, or even sepsis and death.
INFLUENZA IN ELDERLY
• The manifested non-specific
signs and symptoms (delirium
syndrome, postural instability
and fall) may cause further
the elderly.
• Influenza complication in
geriatric patient usually will
also affect the patient’s
dependency level. →that there
was decreased ADL
• The primary strategy for prevention
of influenza disease is vaccination.
• Although the vaccine is less efficacious
• Vaccines against influenza currently, in preventing clinical illness in older
a trivalent inactivated vaccine is used adults as compared to younger adults, it
(A/H1N1, A/H3N2, B) has been proved that it lessens the
severity of infection and is 80%
• Recently, quadrivalent vaccines effective in preventing death in this
became available, as two different B population
strains had circulated in parallel for
several years

• recommendations of CDC, all adults

older than or equal to 65 years of age
should receive influenza vaccine annually

• WHO also recommends annual

immunization of people at risk as the best
and most cost-effective strategy for
reducing influenza-related morbidity and
mortality.
INFLUENZA VACCINE
 Jenis Trivalen inactivated vaccine (influenza tipe A
[H1N1 dan H3N2] serta influenza B)

Dosis 1 dosis (0,5 ml) intramuscular per tahun

Indikasi Seluruh dewasa (≥19 tahun) direkomendasikan untuk
mendapatkan vaksinasi influenza per tahun

Kontraindikasi Reaksi alergi berat (seperti nafilaksis) setelah

vaksinasi sebelumnya, terhadap komponen vaksinasi
termasuk protein telur.

INFLUENZA VACCINE
 • Until now, pneumonia is the
leading cause of death in
hospitalized geriatric patient.
• The prevalence of pneumonia at
acute geriatric ward of Cipto
Mangunkusumo Hospital in 2000
was 54.8% with mortality rate
reached 32.5%.
PNEUMONIA IN ELDERLY
• The elderly is more vulnerable to
infection as they own impaired
physiological immune system
and reduced lung function, i.e.
suppression of the cough reflex
and decreased function of
mucocilliary epithelial in the
respiratory tract; therefore, the
risk of pneumonia in the elderly
increases.
 • Initial symptoms are not specific.
• The common constitutional symptoms are weakness,
loss of appetite and no eagerness to do activities.
• Patients are usually admitted to hospital due to fall,
unconsciousness or exaggerated dyspnea.
• Physical examination may reveal acute confusional
state or delirium syndrome.
• In many cases, the patient may experience various
complications including respiratory failure, respiratory
acidosis, sepsis and even death.
• the healing process may be prolonged causing high
medical and hospitalization cost.
PNEUMONIA IN ELDERLY
• patients usually have impaired functional
state, which cause great dependency upon
other people or having high dependency
level to perform their activities of daily
living
• Pneumonia in geriatric patients often has
clinical presentation of postural instability,
which may cause fall. Femoral fracture,
immobilization, incontinence, contracture,
decubitus and sepsis are conditions
commonly found in geriatric patients with
pneumonia. → impaired quality of life in
the elderly patients
 • A 23-valent polysaccharide vaccine (PPSV-23) has been
used for many years for older adults

• As PPSV-23 is a polysaccharide vaccine, it elicits only T-

cell-independent antibody responses, induces no
immunological memory and does not show a booster effect
upon repeated vaccination.

• A 13-valent conjugate vaccine has been introduced also for

older adults.

• Some countries still recommend the polysaccharide vaccine,

while others recommend the conjugate vaccine alone or
followed by the polysaccharide vaccine usually at least one
year later.

PNEUMOCOCCAL VACCINE
Jenis Pneumococcal polysaccharide vaccine-23
(PPSV-23)
Dosis Dosis tunggal (0,5 ml) intramuscular atau
subkutan
Indikasi Seluruh dewasa ≥65 tahun, atau dewasa ≥19
tahun dengan faktor risiko tertentu. Dosis
perlu diulang setiap 5 tahun.
Kontraindikasi Reaksi alergi berat (seperti Anafilaksis)
setelah vaksinasi sebelumnya, atau terhadap
komponen vaksin

Jenis Pneumococcal conjugate vaccine-13 (PCV-13)

Dosis Dosis tunggal (0,5 ml) intramuscular atau subkutan
Indikasi Seluruh dewasa ≥65 tahun, atau dewasa ≥19 tahun
dengan faktor risiko tertentu. Dosis perlu diulang
setiap 5 tahun.

Kontraindikasi Reaksi alergi berat (seperti nafilaksis) setelah

vaksinasi sebelumnya, atau terhadap komponen
vaksin
 • The incidence of herpes zoster increases • reactivation occurs once T-cell-
with age and it has been estimated that
up to 50% of all cases affect persons > 85
mediated immunity against
years varicella zoster virus falls below a
crucial level because—compared
• The most common complication of herpes with young adults—fewer
zoster is PHN, which is characterized by varicella zoster virus specific T
persistent pain for months after acute cells are detectable in the elderly
herpes zoster.
(due to immunosenescence )
• Especially in the elderly, PHN can have a
dramatic impact ADL → to loss of
independence and institutionalization

Herpes zoster in elderly

• A single-shot immunization
with an attenuated live-
vaccine against herpes zoster, Jenis Live-attenuated varicella-zoster virus

which has been licensed for
use in older adults in 2006, is
recommended in some
countries.
• This vaccine has been shown
to induce antibody and T-cell
responses in the elderly and in
a large study proved to be
clinically efficient because
vaccination reduced the
incidence of herpes zoster by
51.3% in the total population.
Dosis Dosis tunggal (0,65 ml) subkutan
Indikasi Seluruh dewasa ≥60 tahun, dengan atau tanpa kejadian
herpes zoster sebelumnya. Vaksinasi juga dapat
diberikan pada individu dengan berbagai penyakit
kronis, kecuali yang termasuk dalam kontraindikasi.
Food and Drug Administration (FDA) telah menyutujui
pemberian vaksin usia populasi berusia ≥50 tahun.
Kontraindikasi  Individu imunodefisiensi, termasuk tuberculosis
aktif
 Memiliki riwayat anafilaktik atau reaksi
anafilaktoid terhadap komponen vaksi

• The incidence of postherpetic  Telah mendapat antivirus terhadap herpes-zoster

neuralgia was reduced by sebelumnya (dalam 48 jam), seperti asiklovir dan
66.5% sebagainya. Obat tersebut harus dihindari selama

Herpes Zoster
10 hari setelah pemberian vaksinasi zoster.
 Beberapa bank darah menyarankan untuk

vaccine menunda donasi darah hingga 30 hari setelah

vaksinasi
Vaccines, not specifically recommended for the elderly, but
administered to all adults, should also be evaluated in
persons > 60 years.
• Vaccination against tetanus (Clostridium tetani), diphtheria
(Corynebacterium diphtheriae) and pertussis (Bordetella
pertussis) is recommended every 10 years in many
countries.
• TRAVEL VACCINES
• As a consequence of the increased life expectancy and
mobility of elderly persons,→ a substantial fraction of
travellers in tropical areas are currently of advanced age
• Travel vaccines are therefore an emerging issue in the
context of vaccination of the elderly.
Other Vaccines
• Vaccination against diseases
such as typhoid and yellow fever,
Japanese encephalitis and rabies
will be a first contact with neo-
antigen for most elderly
travellers.
• Vaccinations against Hep A & B
• It is crucial to vaccinate early
enough before travelling to allow
for the development of an
adequate antibody response, for
titre controls, and eventually for
booster vaccination, if there is
no adequate protection.
 • Despite major advances in the field of vaccinology over the last decades,
there are still possibilities for improvement, particularly concerning vaccines
for the elderly.

• Most existing vaccines are less immunogenic in the elderly and many
different strategies are currently pursued to optimize vaccine efficacy in the
elderly.

• Recent research focuses on the development of novel adjuvants, which

enhance or modulate vaccine-induced immune responses and could be
useful to improve the immunogenicity of various antigens in the elderly.

• Currently, no vaccines are available against nosocomial bacterial infections

• As elderly persons are hospitalized more frequently they could be a primary

target for those vaccines. However, little research is currently dealing with
these issues.

• Staphylococcus aureus, particularly methicillin-resistant strains, Clostridium

difficile, E. coli, Klebsiella pneumoniae and—albeit not a bacterial infection—
Candida spp. could be considered as targets for vaccine development

FUTURE CHALLENGES
 • Older adults are at high risk for infectious diseases and
vaccination is an important preventive measure to
facilitate healthy aging.

• The first step towards optimal protection of the elderly is

the comprehensive use of existing vaccines.

• Public awareness is needed that not only children, but

also adults, and in particular the elderly, benefit from
vaccination.

Conclusion
THANK YOU 